seminar 5 safety management system

WorkSafe Victoria is a division of the Victorian WorkCover Authority

6 June 2006

Seminar 5Safety Management System

Mike ConnellDannae CampbellSarah Sinclair Wayne Williams

What is a Safety Management System?

• “An orderly arrangement of interdependent activities and related procedures that drives an organisation’s performance.”

1996

• “A Safety Management System is an integrated set of work practices, beliefs and procedures for monitoring and improving the safety and health of all aspects of your operation.”

CASA, July 2002


• “That part of the overall management systems which includes organisational structure, planning activities, responsibilities, practices, procedures, processes and resources for developing, implementing, achieving, reviewing and maintaining the OHS policy, and so managing the risks associated with the business of the organisation.”

AS/NZS 4801, 2001


What do we make of this?

• A mixed bag

• Software not hardware (paper warfare)

• Can be repetitive or mundane

• But VITALLY important!!

5

Alcohol& Drugs

PolicyAudit Plans

Road Safety Plan

Safety Drills

Security Policy

SafetyPolicy

No Structure Structure

Policy

Process

Task

ContinuousImprovement

Safety (HSE Cases)

Mgt.policy


Our Challenge today

• Explain what is needed under the Regulations

• Show what makes a good SMS

• Reconfirm the importance of the SMS at a MHF

• Show what to look for in Round 2 review and revision of the SMS

• AND make it interesting!!

Program for today

• Regulations

>What do they ask for?

>What does WorkSafe look for?

Break

• SMS approaches in use at MHF’s

• SMS elements required for risk control

• Questions

Break

Program for today

• Case Study of SMS element failure

(Piper Alpha)

• Experience from Round 1 and Annual Inspections

Break

• Auditing and Performance Monitoring

• Operator presentation – Round 2 review & revise SMS

Melbourne Water Ms Charmaine Quick

• Guidance for Round 2 submission

• Questions

Safety Case Assessment and the MHF Regs

What is Safety Case Assessment?

A process which uses desktop assessment and onsite verification to see if you comply with the regulations.i.e. meet the performance standard

Our performance standard for assessing your SMS:

The MHF regulations and known SMS Standards which you may subscribe to. (eg. Australian Standards, your own corporate policies)

Our assessment tools: Focus Rule 7 – Safety Management Systems, Focus Rule 8 – Safety Case Demonstrations and your own SMS KPI’s

Why do WorkSafe verify the SMS?

Verification obtains evidence to show that your SMS is implemented and functional as you describe it.

We also verify that your employees

• have access to the SMS• understand their duties in following procedures• have been provided information, instruction and training • where practicable have been consulted in SMS development/

changes• have been involved in review/revise process

Examples of information needed to assess & verify your SMS

• Your SMS summary and selected procedures• Samples of auditing and proof of corrected non conformances• Proof of monitoring of SMS KPI’s• Work Safe’s observations from oversight and annual inspection• Review of changes as a result of the review and revise • Training records • Interviews with your employees, contractors and HSR’s • Position descriptions• Contractual details if the management of control measures is

outsourced

Why do WorkSafe perform these processes ?

Because of your need to demonstrate compliance before you can get a licence

What are the drivers for demonstration?

Drivers for demonstration - The CEO signed statement

Reg 402(3)(a) and (d)

A Safety Case must contain a signed statement bywhich the operator certifies that -

The summary of the SMS is an accurate summary

The persons who participate in the implementation of

the SMS have the knowledge and skills necessary to

enable them to perform their allocated tasks and discharge

their allocated responsibilities in relation to the SMS

Drivers for demonstration - Granting of a licence

803(1)(a)

The Safety case has been prepared in accordancewith regulation 402

Reg 402

The content of the safety case must be sufficient for the purposes of

(a) Demonstrating that the safety management system provides a comprehensive and integrated management system for all aspects of control measures adopted in relation to hazards and major incidents

Have you given your assessor enough information for them to confidently state that demonstration is adequate?

Because WorkSafe can suspend or cancel licences

Regulation 808(2)

The Authority may suspend or cancel a licence if the Authority is satisfied that -

(a) The SMS for the licensed MHF no longer provides a

comprehensive and integrated management system for all

aspects of control measures adopted in relation to hazards and

major incidents

Granting of licence

The Authority may grant a licence if,

803(1)(b) The applicant has complied with provisions of part 3 of the Regs;

Part 3 of the MHF regs:SAFETY DUTIES OF THE OPERATOR

Safety duties of operators

Regulation 301(1)

The operator of a major hazard facility MUST ESTABLISH

and IMPLEMENT a SMS for the major hazard facility

When is your SMS established?

When is your SMS implemented?


Regulation 301(2)

The operator MUST USE the Safety Management System as

the PRIMARY MEANS of ensuring SAFE OPERATION of

the Major Hazard Facility

Does not say ‘preventing Major Incidents’

What does “primary means” mean to your site?


Regulation 301(3)

The Safety Management System so established MUST

(a) provide a COMPREHENSIVE and INTEGRATED management system for all aspects of CONTROL MEASURES adopted under Part 3

(b) be DOCUMENTED

(c) Be so set out and expressed that its contents are readily ACCESSIBLE and COMPREHENSIBLE to persons who use it

Is your SMS providing comprehensive (effective) management of your control measures?

Are you confident that your SMS supports your CM’s for all aspects?


Reg 301(4)

The SMS MUST

STATE the operator’s safety POLICY, including the operator’s broad AIMS in relation to the SAFE OPERATION of the major hazard facility;

State the operator’s SPECIFIC safety OBJECTIVES;DESCRIBE the SYSTEMS and PROCEDURES by which these OBJECTIVES are to be ACHIEVED;

Describe how COMPLIANCE with PART 3 & PART 5 is to be achieved;(part 3: Safety duties of operator), part 5 (consulting, informing instructing and training)

INCLUDE all matters specified in SCHEDULE 2


Schedule 2 – Additional matters to be included in the SMS

Safety policies and objectivesOrganisation and personnelOperational controls Compliance with part 3 & part 5 of the regulationsManagement of changePrinciples and standardsPerformance monitoringAudit

Performance monitoring and

Audit will be covered later in this presentation


Reg 301(5)

The operator must REVIEW and as necessary REVISE the Safety Management System if

• a MODIFICATION is made to the major hazard facility;• a MAJOR INCIDENT occurs at the major hazard facility;• whether or not the circumstances mentioned in paragraph (b)

or (c) occurs, AT LEAST ONCE EACH 5 YEARS.

To what extent are you going to review/revise your SMS? Document this in your review/revise plan


Reg 307(1)(d) Safety roles for employees

The operator of a MHF must develop a role for the operator’s employees including the specific procedures they would be required to follow to assist the operator in relation to

Establishing and implementing a SMS under regulation 301.

Who writes and/or updates your SMS?Who implements your SMS?Who is responsible for making sure your SMS is adhered to?

Interpretation of terms

Comprehensive?Describes the way that all safety issues including controlmeasures are managed Clear link between CM management and the SMS

Integrated? The structure is logical, systematic Logical tie-ins to other management systems Corporate systems do not contradict onsite systems

Comprehensible?Abbreviations and terms used mean something to employeesConsideration of language issues

Interpretation of terms

Implemented?Procedures are approved and in circulationEvidence is available – completed forms and/or checklists Employees are trained and knowledgeable

Accessible?Employees are aware how to obtain the most up to date or relevant proceduresEmployees can obtain the SMS information needed to support control measures

Consulting, informing, instructing and training

Reg 501 Consultation with health and safety representatives

501(1)(d) The operator of a MHF who is establishing and implementing a SMS under regulation 301 must if practicable consult with the HSR of each designated work group to which the operator’s employees belong

What has happened now with the new Act?

OH&S Act 2004 – Duty of employers to consult

Part 4, section 35(1)

Duty to consult is now wider than MHF regulations originally intended for SMS

Where practicable employers need to consult with employees* on:

Proposed changes about conduct of work Provision of information/ training Identifying/assessing hazardsMaking decisions about controls

* Employee includes, independent contractors and any employees of independent contractor

Consulting, informing, instruction and training

502(1) (d)

The operator of a MHF must provide their employees with such information, instruction and training in relation to

- the content and operation of the SMS generally as are necessary to enable the employees to perform their work in a manner that is safe and without risk to health

Consulting, informing, instruction and training

503 (b) Further information and access to documents

The operator of a MHF must ensure that the SMS, the SC and the Emergency Plan or copies of these documents are readily accessible to the operator’s employees

Are you confident that your employees always have easy access to the most up

to date information?

Duties of employees

Reg 601 (1) (a)

An employee at a MHF must follow the operators procedures relating to the prevention and control of major incidents within the MHF

Your SMS should tell your employees what they have to do to remain safe!

The Safety Case

Reg 402(1)(a) Content of the SC

A safety case prepared or revised under this Part must –

Contain a summary of the content of the SMS established under regulation 301

Are you satisfied that your summary adequately describes how your SMS works?

The Safety Case

Reg 402(1)(c) Include the information specified in schedule 4

A statement as to how existing control measures and the SMS are capable of maintaining safe operation of the MHF

At all points in the SC where the matter addressed is covered by the SMS a clear reference to the relevant part of the documented SMS

A description of those parts of the documented SMS which address the maintenance of the SMS (that is, its ongoing effective implementation and its ongoing improvement)

The SC describes your SMS and justifies decisions based on assessment of risk


Safety Management Systems

Theory & Practice

Sarah Sinclair

Business Improvement Unit, WorkSafe Victoria

Definition of a Management System

• Orderly arrangement of interdependent activities and related procedures that drives an organisation’s performance

• SMS - controlling risk through a management process

ISO 14001 Environmental Management Systems

BS OHSAS 18001 Safety Management Systems

EnvironmentalPolicy

ManagementReview

Planning

Implementation& Operation

Checking &Corrective Actions

OH&SPolicy

ManagementReview

Planning



Common Elements of Management SystemsAS 4801

Measurement

& Evaluation

OHS Management System Model - AS 4801

gg

OHS Policy

Planning


ImplementationChecking&CorrectivActio

Measurement& Evaluation

ContinualImprovement

ManagementRevie

ManagementReview

Orderly Arrangement - Key Elements of a SMS

HSE Model(HSG65)

Policy development

Organisational development

Developing techniques of planning, measuring and reviewing

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Policy

Effective health and safety policies set a clear

direction for the organisation to follow.

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Organising

An effective management structure and arrangements are in place for delivering the

policy.

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Planning

There is a planned and systematic approach to implementing the health and safety policy

through an effective health and safety management system.

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Measuring Performance

Performance is measured against agreed standards to

reveal when and where improvement is needed.

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Auditing and Reviewing of Performance

The organisation learns from all relevant experience and

applies the lessons.

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More simply….

PLAN

CHECK

ACT DOHealth

& Safety

Activity

• Allocate all Schedule 2 SMS requirements into the key elements of your SMS (regardless of what you call the key elements)

OH&SPolicy

ManagementReview

Planning



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Frequently Asked Questions

• How big should the SMS be?• What should the SMS be called?• Should the SMS be integrated with other systems eg

quality?• How many topics/groupings should there be in the SMS?• Should the SMS be on paper or electronic?

Answers….

Be appropriate for your site

History of your SMS?

• Corporate (appears from on high)• Built from ground up• Tacked onto quality system (ISO 9000 or Lloyd’s accredited)• Bought off-the-shelf model from consultant• SafetyMAP• AS 4801• From supplier or customer

Which SMS is best?

Suit your site (eg number of people, type of hazards, experience with systems etc)

Meet MHF Regulations

MHF Regulations & SMS

SAFETY MANAGEMENT SYSTEM (Reg 301)

SAFETY ROLE FOR EMPLOYEES (Reg 307)

Consulting, Informing, Instructing Training (Part 5)

MONITOR AND REVIEW (Reg 306)

ASSESS RISKS – LIKELIHOOD & CONSEQUENCE (Reg 303)

DECIDE ON CONTROL MEASURES (Reg 303(4))

IMPLEMENT CONTROL MEASURES (Reg 304)

IDENTIFY MAJOR INCIDENTS & HAZARDS (Reg 302)

SMS & Control Measures

Regulation 301(3)

The SMS must provide a comprehensive and integrated management system for all aspects of control measures adopted under Part 3.

SMS Control Measures

SMS & Control Measures

IncidentsHazardsCauses Outcomes

PreventionControls

MitigationControls

“Threats”‘MI’ Potential

Local procedures and practices (design, maintenance & operation)

Corporate Safety Management SystemLevel 1

Level 2

Level 3

Pitfalls of Safety Management Systems

• Off the shelf

• Global system

• Head office audits us once every few years

• Based purely on the regulations

• External accreditation

• Quality ≠ safety

• Occurred prior to restructure

• Outsourcing

• Auditing unrealistic


Thank you

SMS and risk control

The Role of SMS elements in Major Incident prevention and control

Learning from others’ experience

Buncefield Oil Storage Depot - UK

6.00AM Sunday 11 December 2005• Several explosions. At least one “of massive

proportions”• Large fire engulfed more than 20 large fuel storage

tanks

On-site consequences• 43 people injured, none seriously• Fire burnt for several days• Large number of tanks destroyed

The Incident

Buncefield Oil Storage Depot - UK

• “Significant damage” to commercial and residential neighbours

2000 people evacuated• Sections of M1 Motorway closed• Very large smoke plume over Southern England

→ Air pollution• Large quantities of foam and water →

Contaminated water courses and ground water

Off-Site Consequences

Buncefield Incident - Direct Cause

• HSE/EA investigation has now determined direct cause: still investigating root causes.

• “Tank 912 ……. overflowed at around 05.30 hours …….. while being filled at a high rate”

• Large vapour cloud formed and flowed off site• First explosion at 06.01

• Several as yet unanswered questions:-Why was the overflow not detected for so long?-Why was there so much explosive force?

Buncefield Fuel Storage – before incident

Buncefield – During the incident

Buncefield – after the incident

Tank Farm Layout

Basic Layout of Tank 912

Exercise

• were in place?

• could have been in place?

• were they effective?

What control measures

Control Measure Effectiveness

Control MeasuresPreventiveLevel meter & alarmIndependent HLA & TripATG systemOperator surveillance?

Mitigative Ignition source controlFire water systemBunding

Effectiveness

Failed before alarmFlow continuedDid not prevent overflowDid not prevent overflow

Vapour cloud went off sitePump house destroyedPenetrations / joints failed

Exercise

What SMS elements were needed to ensure that the Control Measures worked when required?

Associated SMS Elements

Control MeasuresPreventiveLevel meter & alarmIndependent HLA & TripATG systemOperator surveillance?

Mitigative Ignition source control

Fire water systemBunding

Supporting SMS

Testing & inspection?Critical Function Testing?PM program?Operating Procedures & Training

(Design stds/ purchasing specs?)Design Standards?Maintenance & inspection?

Albright & Wilson incident from Seminar 3

Albright and Wilson, Avonmouth, UK 1996A road tanker of sodium chlorite was accidentally off-loading to two tanks containing epichlorohydrin due to a mix-up with delivery documentation.

What control measures could have been in place here?

Albright & Wilson incident


Texas City Incident from Seminar 3

Texas City, March 2005Fire and explosion; 15 dead, over 170 injured

What control measures could have been in place here?

Texas City incident


Swiss Cheese Model

Some holes dueSome holes dueto active failuresto active failures

Other holes due Other holes due toto

latent conditionslatent conditions

Successive layers of defences, barriers, & Successive layers of defences, barriers, & safeguardssafeguards

HazardsHazards

LossesLosses

Control Measures and SMS

IncidentsHazardsCauses Outcomes

Local procedures and practices (design, maintenance & operation)

PreventionControls

MitigationControls

“Threats”

Corporate Safety Management System

‘MI’ Potential

Level 1

Level 2

Level 3

Lessons for SMS at MHFs

• Identify ALL control measures needed to reduce risk SFARP

• Check that there are SPECIFIC SMS elements for all specific control measures (don’t just rely on corporate SMS)

• Make sure that the SPECIFIC elements are IMPLEMENTED, FUNCTIONAL (as in the Safety Case) and AUDITED

76

Questions?

Piper Alpha, North Sea

July 6, 1988, killed 167 men

Most of the victims suffocated in toxic fumes which developed after a gas leak set off the blasts and sparked the fire

In November 1990 Lord Cullen's report into the disaster severely criticised safety procedures on the rig owned by Occidental Oil

Piper Alpha, North Sea

“A litany of deficiencies”

What SMS elements should have/ could have functioned effectively to prevent or mitigate this disaster?

Lessons from Round 1 assessment

Lessons from Annual Inspection

In some cases this meant shorter licences for sites who developed their SMS from scratch and

could not demonstrate full implementation/SMS operating history

SC outline – Proposed SMS was ambitious for resources available, and left too late


Fit for purpose SMS

Underestimated the time taken to modify fine detail in corporate standards to satisfy the regulations

Most Corporate SMS met the high level requirements of the regime but not the fine detail

Difficulty in fitting a 1000 page corporate SMS into a 10 person site


SMS development – have a realistic outlook

A mature SMS is likely to take 5-10 years and a few review cycles to create

A SMS in development is probably going to take 1-2 years to write and 2-3 years to bed in



MHF regs don’t cover aspects such as document control

Some sites have found that integrating their EMS/QMS/SMS works for them

Where major hazards and general OHS are managed through separate systems, there are likely to be efficiency benefits from

integrating systems as far as feasible(Demonstrating reg 301 – Primary means)

Using 3rd parties to write an SMS wasn’t always successful Findings during Round 1 indicated that, in some cases, third parties who had been contracted to develop the SC and SMS were working on a different schedule to which the operator intended

In some cases the operator was not being properly informed about, or was not acting on, the results of the third party’s development work

Operators must ensure that there is appropriate management and monitoring of any activities of third party organisations that are critical to SMS development and the control of major hazards



A number of examples were identified where operators’ auditing processes did not detect problems with implementation of management systems

This was due to auditing processes which focussed on the documentation (desktop only) and did not audit use of systems ‘on the ground’

Auditing at MHF’s needs to address not only the contents of the safety management system, but also that it is implemented to the operators satisfaction and functional i.e. managing the risk as intended

Monitoring/audit /review

Lessons from annual inspection

Management of Change

Often applied only to equipment changes and does not cover organisational or procedural changes Risk assessments are not being formalised in the manner specified in the procedureSafety Case not updated in timely manner to reflect change

Training

Aspects of training not formalisedCore training not identified in Safety CaseTraining on high risk activities not prioritisedPoorly resourced (more significant in sites which are RTO’s)

3rd party management

3rd parties give detailed technical reports back to operator but no review/actioning of non conformances are done by site

Assets managed by third parties are not kept on sites radar i.e.not in maintenance programs. Therefore test interval not knownby operator and can not be tracked

Contractual arrangements do not define KPI’s or COP’s - 3rd party

Outsource to subcontractor and MHF unaware and has no control



Permit to Work

Lists of personnel for authorising and receiving permits were not current

Permit issuers/receivers not formally trained

Authorisations not conducted diligently

Reasons for improvement notices issued during Round 1

• SMS element no longer represents actual site practice

• Employees not trained in aspects of SMS needed for their work

• Employer did not consult with HSR about changes when it was

practicable

• Sites not auditing

• SMS element not implemented

• Sites not updating the SMS after a modification

Coffee time


Auditing Occupational Health &

Safety Management Systems

Wayne Williams

Management Systems Branch, WorkSafe Victoria

OHSMS : It’s only common sense

OHSMS Audit

Stage 1 & Stage 2 = Standard

Stage 2Does the organisation follow its own system procedures, and are they effective?

Stage 1Does the organisation have a system that meets the required standard?

WH

AT

THEY

SAY

WH

AT TH

EY D

O

Standardeg SafetyMAP, AS 4801

The day to day stuff

The support structures

What they want us to see

What’s being kept from us

Systems – more to them than meets the eye

Audit decision

Evidence gathering

Evidence gathering

• Examination of documented procedures

• Interviews & discussions with employer & employee representatives

• Workplace observation & verification

• Examination of records

Evidence value

• Valid ………….…relevant to audit criterion

• Authentic…..…..authorised document

• Current………….actioned, recorded, up to date

• Reliable…………heard from source, observable

• Consistent……..sampled from a number of sources

• Sufficient……….enough examples/samples

• Preaudit meeting• Document review (desk top activity)• Opening meeting• On site audit activities• Exit meeting & preliminary results• Draft report• Comment & feedback analysed & included• Findings in final report• Recommendations to management• Corrective action plan evaluated• Monitor & follow up

The Audit Process

Audits – benefits and limitations

+ - evaluates the effectiveness of systems- identifies opportunities for improvement- puts regular attention on critical areas- demonstrates commitment- verifies legal compliance

- - relies on auditor knowledge, skills, experience

knowledge of legislation, attention to detail

- depends on audit standard, audit brief and audit process eg time allowed, people made available etc

- continuous improvement may NOT be the primary goal eg certification, self insurer/MHF licence

If at first you don’t succeed …. Give up

Safety Management System

Key Performance Indicators

Developing SMS KPI’s - Regulatory driver Reg 310(4)(e), schedule 2 (7)

SC is to include performance standards for measuring the effectiveness of the SMS which:

•Relate to all aspects of the SMS (not just MI)

•Are sufficiently detailed to ensure that the effectiveness is apparent from the documentation

•Include steps to be taken to continually improve all aspects of the SMS

•SC to include a description of the way in which these performance standards are met

Developing KPI’s – A simplified approach

Get a team of people together - management reps/HSR’s/OHS specialists/ SMS owners/ other interested employees

Have available your safety objectives for the site

Have access to your SMS procedures and personnel who understand how they work on site

Have an understanding of the difference between lead/lag indicators and how they may be measured.

Set the context of the meeting

Workshop possible KPI’s

Gain general consensus

Collect and collate the KPI’s over a 3-6 month period

Hold review meeting and revise if necessary

Developing SMS KPI’s

Challenge is to develop KPI’s which support the operator's safety objectives

Consider SMART - Specific, Measurable, Achievable, Realistic, Targeted

Obtaining management commitment - KPI’s can not be developed in isolation

KPI’s should mean something to the people in your organisation

KPI’s are not set in stone – as your safety culture changes so may your KPI’s

Examples of SMS KPI’s

Permit to work

Management of change

Operating procedures

Auditing

Incident or near miss caused by a failure of this system% permits audited compliant with procedure

Incident or near miss caused by a failure of this system% of plant mod forms completed satisfactorily% temporary changes beyond their time limit

% of procedures completed per plan% of procedures reviewed as per plan

% audits completed to schedule# non conformances closed out/ month

Preparing for Round 2 – Review/Revise SMS

Charmaine QuickManager, M&E Asset Management and Asset Information

Melbourne Water Corporation

Round 2 SMS Review/ Revise

What are the drivers for improving your SMS?

•Those you define in your own SMS

•Regulatory drivers in OH&S Act & Regulations

How do you go about it?

SMS – Your drivers

What’s driving your SMS?

Safer site

Safety culture

More productive

More efficient ?

Your inputs Your outputs

Review and revise - Regulatory driver (301(5)(c))

Define inputs

Performance monitoring information Changes to SMS (MOC)Control measures reviewControl measures performance

reviewNew knowledgeIncident reviewsOrganisational changes Change in responsibilities / accountabilities Changes in corporate SMS policyChanges in auditing processes

Defined Outputs

Updated SMS Updated summary of SMS in the SCUpdate KPI’s Training needs for employees Implementation plan for changes SAFER SITE!

Reviewing your SMS is a team effort

Taken from Guidance note 29

An approach for Round 2

• Start with list/register of CM’s and SMS elements needed to support them

• Check if there have been CHANGES to/in:

- Revised CM’s from review to date

- SMS revisions in MoC register

- SMS issues identified in Root Cause Analysis of incidents

- Performance issues from monitoring & auditing

• Identify and implement any corrective actions needed to address performance issues (if not already done)

• Update SMS (and summary) if needed

Sources of additional information

• Guidance note 29 - Safety Case Review/ Revise • Guidance note 12 - Safety management system • Focus rule 7 Safety Case Assessment - safety management

systems• Focus rule 8 Safety Case demonstrations• Australian government OHS management systems – Safety

MAP 4th edition workbook• AS/NZS 4801:2001 Occupational health and safety management

systems specification and guidance for use• AS/NZS 4804:2001 Occupational health and safety management

systems, general guidelines on principles, systems and supporting techniques.

Sources of Additional Information

• Guidance note on industry lessons from developing and implementing the safety case in Victoria (Pacia -2003)

• Successful health and safety management, HSG65, ISBN 0 7176 1276 7

• Preparing safety reports: control of major accident hazard regulations 1999, HSG190 HSE Books, ISBN 0 7176 1687 8

• Major accident prevention policy and safety management system (Part 2, chapter 4)

• API publication 9100, model environmental health and safety management system and guidance


Questions?

seminar 5 safety management system

Documents

safety management systems

sms summary

sms kpiswhy

safety case assessment

known sms standards

safety case demonstrations

sms development changeshave

overall management systems